Category Archives: General Safety

Remembering Tenerife

By Jeff Marcus, Chief, NTSB Safety Recommendations Division

Forty-three years ago, on March 27, 1977, two Boeing 747s, KLM flight 4805 and Pan Am flight 1736, collided on a runway at Los Rodeos Airport in Tenerife, Canary Islands, killing 583 people. It was the single greatest loss of life in aviation accident history.

The crash was the result of an unlikely series of events—and a flight crew’s responses to them.

To begin with, neither of the two aircraft was initially supposed to be at Los Rodeos Airport in the first place. Both planes had been scheduled to arrive at Las Palmas Airport, also in the Canary Islands; however, Las Palmas had just been the target of a terrorist attack, and the terminal had been evacuated and the airport closed. The two 747s, as well as other arriving traffic, were diverted to the smaller Los Rodeos airport in Tenerife, where they landed safely.

The Los Rodeos Airport had not been equipped to handle the influx of diverted flights and, because of that, on March 27, the airport was congested, and maneuverability issues arose when the airplanes were ready to depart. Pan Am 1736 was ready to depart Los Rodeos to resume its itinerary, but had to wait until KLM 4805, which was obstructing the taxiway, had completed taking on fuel from a refueling vehicle. The captain of the KLM flight was instructed to back taxi down the entire runway, then perform a 180-degree turn in preparation for departure. The Pan Am captain was instructed by air traffic control to back taxi down the runway, then exit on the third taxiway to their left, and to report leaving the runway. The taxiways at the airport were unmarked and the centerline lights were out of service.

Los Rodeos airport was subject to fast-appearing, thick fog, and as the KLM airplane lined up for its takeoff roll, fog enveloped the runway. The Pan Am airplane missed its exit, and its crew did not appear to know their position on the runway. Neither crew could see the other plane, and the tower couldn’t see either plane. The airport was not equipped with ground radar.

Having lost so many sources of information, one last source of information failed: verbal communication between the airplanes and the tower.

Immediately after lining up, the KLM captain who had a sense of urgency to depart before exceeding duty limits advanced the throttles and the aircraft started to move forward. The KLM first officer advised the captain that air traffic control (ATC) clearance had not yet been given. The captain replied, “No, I know that. Go ahead, ask.” The first officer radioed the tower that they were ready for takeoff and waiting for ATC clearance. The KLM crew then received instructions that specified the route that the aircraft was to follow after takeoff. The instructions used the word “takeoff,” but didn’t include an explicit statement that the aircraft was cleared for takeoff. The first officer then read the clearance back to the controller, completing the readback with the nonstandard statement: “We are now at takeoff.” The KLM captain interrupted the first officer’s read-back with the comment, “We’re going.”

The controller, who could not see the runway due to the fog, initially responded with the nonstandard terminology “OK,” which reinforced the KLM captain’s misinterpretation that they had been cleared for takeoff. The controller then immediately added “stand by for takeoff, I will call you,” indicating that he had not intended the clearance to be interpreted as a takeoff clearance. However, a simultaneous radio call from the Pan Am crew caused mutual interference on the radio frequency, which was audible in the KLM flight deck as a 3-second-long shrill sound. This caused the KLM crew to miss the crucial latter portion of the tower’s response. The simultaneous message from the Pan Am crew, “We’re still taxiing down the runway, the Clipper 1736!” was also blocked by the interference and inaudible to the KLM crew. Either message, if heard in the KLM flight deck, would have alerted the crew to the situation and given them time to abort the takeoff attempt.

After the KLM plane started its takeoff roll, the tower instructed the Pan Am crew to “report when runway clear.” The Pan Am crew replied, “OK, will report when we’re clear.” On hearing this, the KLM flight engineer expressed his concern about the Pan Am aircraft not being clear of the runway by asking the pilots in his own cockpit, “Is he not clear, that Pan American?” The KLM captain emphatically replied, “Oh, yes,” and continued with the takeoff.

By the time the KLM captain saw the Pan Am airplane, he could only try to fly over it. The tail of the KLM airplane struck the Pan Am airplane, tearing through the center of its fuselage above the wing. Fuel spilled and ignited on impact. Of the Pan Am passengers and crew, 335 died, mainly as a result of ensuing fire and explosions, and 61 survived.

The KLM airplane lost one engine on impact, and the wings were damaged. The airplane rolled sharply and crashed about 500 feet past the point of collision. All 248 passengers and crew died in the crash and the post-crash fire.

The Tenerife accident provided early lessons for the concept of crew resource management (CRM), which emphasizes that all flight crew members should actively voice their safety concerns, and all crew, particularly senior crew members like the captain, must acknowledge the safety concerns of any crew member. In the Tenerife accident, the captain rushed the takeoff, despite the first officer pointing out that they had not received clearance, and the flight engineer recognizing that the Pan Am airplane had not yet cleared the runway. Despite the flight engineer highlighting the dangerous situation, the KLM captain dismissed the concern and continued the takeoff, which resulted in the tragedy a few seconds later.

The Tenerife accident was a milestone in the study of human factors in aviation accidents. The pressures of the day’s events and delays; the logistics pressures in a regional airport handling a major airport’s arrivals; the communications misunderstanding; and the failure to understand and use CRM practices all led to bad decisions at various points in the accident chain.

Aviation has changed and become safer by leaps and bounds since the crash. As a result of Tenerife, there has been greater emphasis on English as the single working language of aviation, and on the use of standard, concise, and unequivocal aeronautical language.

Tenerife was influential in recognizing that all crew members should feel empowered to speak up, and captains should listen to their safety concerns—an important principle of CRM. The principles of CRM have even been extended beyond aviation  to marine safety, where it is known as bridge resource management, and to medicine, where all doctors and technicians in an operating room are encouraged to voice their concerns, and senior, highly esteemed surgeons are trained to listen to and evaluate any safety concern expressed, regardless of who has the concern.

Humans are an integral part of the aviation system and the system must protect for human error. In 2017, many links of an accident chain were in place at San Francisco International Airport when an Air Canada airplane almost landed on a taxiway occupied by four airliners waiting to takeoff. There were over 1,000 people in those four airliners; the accident would have equaled or even surpassed the death toll at Tenerife more than 40 years earlier. That close call was another reminder of how much is on the line every time human pilots and passengers take to the skies—and how much of a role human factors can play in such tragedies and near misses.

Ensuring Transportation Safety, Even During a Crisis

By Member Jennifer L. Homendy

For the past few weeks, I’ve woken up every morning to a text message from the Virginia Railway Express (VRE) updating riders on its continued service and modified schedule. It’s hard not to think of all the VRE and Amtrak locomotive engineers and conductors that I’ve come to recognize (or know by name—Hi, Willie and Samantha!) over the years, and how dedicated they are to continuing to serve the public during this national emergency. You and your colleagues across the country are heroes. Thank you for all you do.

The safety of transportation workers across all modes is extremely important especially during times of crisis. Our nation’s transportation workforce is essential to getting critical goods to states and local communities and to ensuring that those serving on the frontlines of this pandemic, like medical personnel, grocery store employees, and other essential personnel, are able to continue the fight against COVID-19. Without all of them, we’d be in a much more dire situation. Still, we need to make sure that the transportation workers who are putting their lives at risk daily to make deliveries or get people to work are also safe. That not only means providing them with necessary personal protective gear, but also ensuring any regulatory waivers do not jeopardize their safety or the safety of others.

Since the start of this national emergency, many transportation entities facing staffing shortages due to illness and the need to quarantine have requested emergency relief from certain safety regulations. These entities cite concerns about their ability to deliver critical goods and materials necessary for the country’s welfare while meeting regulatory requirements for inspections, training, and maintenance, to name a few. Although regulatory relief from certain requirements may be necessary during this difficult time, I urge the US Department of Transportation (DOT) to carefully review each request and put measures in place to ensure that the safety of transportation workers, and all others who must travel, remains a priority.

We are all being challenged in ways that we could not have imagined a month ago. People are staying safe by traveling only when absolutely necessary and maintaining a safe social distance from others. Those in the transportation industry are also doing what they can to stay safe while continuing to do the important work of moving the people and goods that keep our nation pushing forward during this crisis.

It’s important that any regulatory relief the DOT determines is appropriate is only temporary. This crisis can seem overwhelming, but as a nation, we will prevail. It’s important that when our lives start to take the path back to “normal,” safety regulations—many of which the NTSB has long advocated for following tragic crashes—are reinstituted. Temporary measures to address a crisis should not become the new normal. An efficient transportation network is key to our nation’s success during this challenging time, but we must not forget the importance of ensuring the safety of transportation workers and the traveling public both now and in the future.

A Tribute to NTSB Employees

By Chairman Robert L. Sumwalt

What do you get when you cross a transportation-related life-saving mission with some of the best people in the federal government?

 The National Transportation Safety Board, of course!

 And that is no April Fool’s joke.

 On this day 53 years ago, the NTSB was formed by an act of Congress. The agency’s mission is to investigate every civil aviation accident in the United States and significant accidents in other modes of transportation, determine their probable causes, and issue safety recommendations aimed at preventing future accidents. In addition, we conduct special studies concerning transportation safety, and we coordinate the resources of the federal government and other organizations to provide assistance to victims and their family members impacted by major transportation disasters. We also adjudicate appeals from civil enforcement actions by the Federal Aviation Administration and the United States Coast Guard.

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Since 1967, the NTSB has investigated more than 149,000 aviation accidents and thousands of surface transportation accidents. We’ve issued more than 15,000 safety recommendations—the vast majority of which ultimately are implemented. Some of the safety measures that have arisen, at least in part, from our safety recommendations include:

Aviation

  • Floor-level escape lighting, fire-blocking seat coverings, lavatory smoke detectors, stronger cabin seats
  • Terrain avoidance and warning systems requirements
  • Inert gas use to eliminate fuel tank explosions
  • Shoulder harnesses in general aviation

Highway

  • Raising the legal drinking age to 21 and .05 percent BAC drinking and driving laws
  • Child passenger safety
  • Enforcement of commercial vehicle regulations

Marine

  • Boating-while-intoxicated laws
  • Cruise ship fire safety
  • Emergency position-indicating radio beacons (EPIRBs) on vessels

Railroad & Rail Transit

  • Positive train control
  • Passenger rail car safety standards
  • Toll-free emergency number posting at grade crossings
  • Tank car enhancements

Pipeline

  • One-call systems before excavation (“Call 811 Before You Dig”)
  • Integrity management programs
  • Facility response plan effectiveness and oversight

HAZMAT

  • Hazard communications training for first responders, community planning, and preparedness

I’m often reminded that you can have an important mission, but if you don’t have devoted, talented employees, you really don’t have a great agency. Fortunately, the NTSB has both.

Our mission generates dedication, which often translates to retention; some of our longest-serving employees have been at the agency for over 40 years. But don’t misinterpret that longevity as complacency. In the most recent Federal Employee Viewpoint Survey, of the 70% of NTSB employees who completed the survey, 97% responded favorably to the statement, “When needed I am willing to put in the extra effort to get a job done.” Bear in mind that in many cases, “extra effort” is in addition to routine travel to remote accident sites with only hours’ notice!

During more than 13 years at the agency, including the past 3 as Chairman, I’ve had the pleasure to be surrounded by, and to work with, these professionals. As Chairman, I have relied on them to help formulate strategic decisions, advise me on technical details, and echo and amplify my own thirst for safety improvements.

Many of our air safety investigators are pilots and aircraft mechanics themselves—and each of them can tear down an engine. Several have built their own airplanes. Many of our highway safety investigators come from law enforcement backgrounds. Our marine investigators generally maintain licenses first earned as deck and engine officers or have Coast Guard investigative or regulatory experience. Our railroad and pipeline investigators are veterans of those industries and their regulators as well. Although doctoral degrees are common throughout the agency, the environment is as far as you can imagine from an ivory tower.

The NTSB workforce is among the best in the federal government, which is what fuels my desire to make the NTSB the best place to work in the federal government—even if, for now, we have temporarily moved that workplace into our homes.

Today, like many workforces, we are physically distant from one another, but we are not alone. We are physically separate, but we will get through this together. I’m grateful for the dedication and resilience of every one of NTSB’s employees. And that, too, is no April Fool’s joke.

Attributes of a Healthy Safety Culture

By Chairman Robert L. Sumwalt

I recently wrote a series of social media messages about attributes of a healthy safety culture. I received some interesting feedback and cross-talk from organizational safety leaders, so I wanted to make the collected messages available in PDF form for this blog’s readers.

Attributes of a Healthy Safety Culture

Click on any of the attributes listed below to read the original messages.

I hope that, after viewing these messages, readers look around their operations, note where an attribute is lacking from their organization’s safety culture, and consider whether the shortcoming presents an opportunity for improvement. As widely known expert on organizational accidents James Reason said, “There are no final victories in the struggle for safety.”

While writing these messages, I realized again how integrally enmeshed personal and organizational responsibility are in the safety journey. The active error committed by one employee might not have been committed by another, but the same employee who committed the error might not have done so in another organization. Furthermore, in addition to individuals, an organization might be at the root of an accident.

Continuous safety improvement takes both conscientiousness and boldness to voluntarily identify what might go wrong and to think through the “what ifs” on the way to mitigating risk. It’s a tall order, and my hat is always off to those who accept the challenge—our safety professionals.

I hope that these musings will be of value to you and your colleagues as you move forward in your safety journey!

A Comprehensive Approach to Bicycle Safety

By Member Jennifer Homendy

Last fall, the National Transportation Safety Board released a report that made safety recommendations meant to improve safety for an important and growing segment of users on our roadways – bicyclists. The report issued 12 new safety recommendations and reiterated 10 safety recommendations.

Through NTSB’s 50+ years of accident investigation experience, we’ve long known that complex challenges, like reducing the number of vehicle-bicycle collisions, requires multi-faceted solutions. In the study, we looked at numerous countermeasures, including roadway design and infrastructure, reducing traffic speeds, collision avoidance systems and blind spot detection systems.

Homendy-bikePerhaps that is why I was disappointed to see the controversy within the cycling community surrounding one of the 22 recommendations discussed in the report – the singular recommendation about requiring the use of helmets. That debate overshadowed the many other important recommendations that largely focused on preventing collisions between vehicles and bicyclists in the first place, rather than mitigating their severity. As an avid cyclist myself, I am very aware of the hazards that exist for cyclists and share the community’s concern for improving bicycle safety on U.S. roadways.

Separated bike lanes and bike-friendly intersections are incorporated in the design of just a tiny fraction of U.S. roadways. So, we asked for more. The NTSB recommended that guidance provided to highway engineers, city planners and traffic designers, include resources that will help increase bike-friendly roadway improvements throughout the U.S.

Along with changes in infrastructure, the NTSB found that reducing traffic speeds can reduce the likelihood of fatal or serious bicycle injuries. Lowering speed limits is part of a safe systems approach that was also discussed in our 2017 safety study on reducing speeding-related crashes.

Collision avoidance systems are broadly effective in helping motorists detect and avoid other vehicles and some automakers have begun adding systems to detect bicyclists and pedestrians.  To encourage manufacturers to include these systems in their new vehicles, and to assist auto buyers in making safety-conscious purchasing decisions, the NTSB recommended that bicycle detection systems be incorporated into the 5-Star Safety Ratings.

The NTSB also recommended that newly manufactured large trucks be equipped with blind spot detection systems, because large vehicles have bigger blind spots that make it difficult, or even impossible, in some situations for their drivers to see bicyclists.

And as a Board Member, I will continue to push for the implementation of safety recommendations on the NTSB’s Most Wanted List that would help make streets safer for bicyclists – including eliminating distractions, reducing fatigue-related accidents, ending alcohol and other drug impairment, increasing implementation of collision avoidance systems and reducing speed-related crashes.

Member Homendy Bike Safety Study Board Meeting

Implementation of our recommendations would dramatically improve the safety of our roadways for bicyclists. But prevention or avoidance will sometimes fail and mitigating the severity of crashes will help save lives. That basic premise of transportation safety, supported by data on fatalities from head injuries, prompted our call for helmets for bicyclists.

The NTSB’s approach to bicyclist safety is comprehensive, multi-faceted and fact-based. All the safety recommendations, when implemented, would help save lives by preventing collisions from happening, and by reducing the severity of those that do.

Automation Complacency: Yet Another Distraction Problem

By Vice Chairman Bruce Landsberg

 The NTSB first issued a recommendation to ban the nonemergency use of portable electronic devices (PEDs) while driving in 2011, and the issue area “Eliminate Distractions” remains on the 2019–2020 Most Wanted List of transportation safety improvements. Web browsing, texting, calling (even hands-free)—all these activities significantly increase the chance of a distracted‑driving crash, which is why we’ve recommended banning driver use of PEDs in all states. Most states have prohibited texting and handheld PED use in some form.

The science is clear: our addiction to PEDs is growing exponentially, placing constant connectivity and convenience above driving responsibly and resulting in tens of thousands of completely preventable, and often tragic, crashes. Driving while distracted by a PED is dangerous and it’s completely preventable. Simply, the decision to drive distracted is dumb.

Distraction by PED is becoming the “old” kind of distraction, as automated and semi-automated vehicles enter the roadways. These new technologies are creating a new and equally menacing kind of distraction: automation complacency. Overreliance on these advanced driver assistance technologies lulls drivers into a false sense of security. They trust in the machine and believe that frees them up to text, e-mail, or watch a video. With automation complacency, human nature asserts itself. We evolve to the idea that we will probably never have to intervene when a computer is doing the driving. The mind creates a rule based on positive prior experience; after so many seamless rides in an automated vehicle, we begin to relax our guard.

A tragic illustration of this growing phenomena is the March 18, 2018, fatal crash in Tempe, Arizona, involving a pedestrian and an Uber vehicle with an experimental automated driving system. The Uber’s safety driver was expected to intervene only if needed, a task that required the driver’s full engagement in and focus on the driving task. Instead, in the half hour prior to colliding with and killing the pedestrian, the driver spent more than a third of her time gazing down at the center console, sometimes for as long as 26.5 seconds. The vehicle’s onboard camera recorded the driver watching streamed content on her cell phone through most of the crash sequence.

Tempe, Arizona crash
NTSB investigators on-scene in Tempe, Arizona, examining the Uber automated test vehicle involved in a March 18, 2018 collision with a pedestrian.

Humans are creatures of habit and this driver had traveled this route more than 20 times in the test vehicle with no incident. Simply put, she was bored. She failed to remain vigilant and succumbed to automation complacency, believing the system would detect pedestrians under all circumstances—even when crossing outside of a crosswalk at night. Our investigation of this fatal crash determined that an attentive human driver would have easily avoided the pedestrian.

If it’s hard to convince drivers to stop multitasking while driving a vehicle that is not equipped with an advanced driver assistance technology, then it’s going to be that much harder to convince drivers to stay alert in a highly automated vehicle. The fact is, there is no commercially available vehicle in the United States that is fully autonomous and doesn’t require the driver’s full attention to the driving task.

The companies testing automated vehicles on public roads, the states where these vehicles are tested, and the National Highway Traffic Safety Administration must work to prevent this emerging form of distraction from increasing and placing roadway users at increased risk, particularly vulnerable users such as bicyclists and pedestrians. Now is the time to get ahead of the problem.

 

 

Do You Have a Super Bowl Transportation Game Plan?

By Leah Walton, NTSB Safety Advocate

Super Bowl LIV is almost here! Whether you’re a diehard 49ers or Chiefs fan, or you simply watch for the commercials and halftime show, the play clock is just about to hit 0. For many football fans, driving will be part of the game plan both before and after the Super Bowl, regardless of if they’re driving over 3,000 miles to Hard Rock Stadium or simply going across town to a playoff party. Either way, safe transportation plans must be part of every driver’s Super Bowl game plan.

Football is a game driven by statistics. As Chiefs’ Head Coach Andy Reid takes in stats for his Super Bowl game plan, consider these highway safety facts as you prepare your own playbook.

Driving fast with a sport car

So, what should your Super Bowl transportation game plan look like? First, drive sober or designate a sober driver. Recognize that even a moderate amount of alcohol or certain drugs will make driving unsafe. If you don’t have a designated driver, a taxi, public transportation, or rideshare charge will be a minor cost compared to a DUI—or worse. Second, don’t drive fatigued. Immediately after the game and before work the next day, check yourself to see if you are rested enough to drive safely. If you got less than 7 to 9 hours of sleep, recognize the need to take breaks, take a nap, or find another mode of transportation. Third, don’t drive distracted—the postgame highlights, commentary, and selfies can wait until you safely arrive at your destination.

Whether you’re rooting for the 49ers, Chiefs, or simply a good game, make sure you have a designated sober driver in your Super Bowl lineup, and follow this gameday rulebook!